Post on 28-Dec-2015
Physical Activity and Cardiovascular Disease
ANDREAS PITTARAS MD
Survival of the Fittest
“…in the last 15 years, many epidemiological studies have shown
an unequivocal and robust relationship of fitness, physical activity, and exercise to reduce overall and CVD mortality.”
Balady JG, New Engl J Med 2002;346 (11):852-53
Coronary Heart Disease and Physical Activity of Work
Morris JN, et al. Lancet 1953:2:1053-1120
Approximately 50% lower risk of CHD in those with physically demanding (i.e. mail carriers) vs those with sedentary
occupations (i.e. desk clerks).
Physical Activity and the Incidence of Coronary Heart Disease
Powell KE, et al. Annu Rev Public Health 1987; 8:253-87
• 121 studies reviewed; 43 were included.
• The relationship between sedentary lifestyle and increase risk of CHD is likely to be causal.
Relative Risk for CAD
1.92.1
2.4 2.5
0
1
2
3
Ann Review Public Health 1987; 8:253-87RR
Physical Inactivity
SBP>150 mm Hg
TC>268 mg/dL
Smoking >1 pack
Population Attributable Risk by Risk Factor
0
10
20
30
40
50
TC Inactivity BP Smoking Obesity Diabetes
Population Attributable Risk (%)
It is Estimated that 250,000 Deaths/Year in the USA are
Attributable to Lack of Regular Physical Activity
Siegel PZ, at al., Weekly Reports 1991
Physical Activity Status in US Population
• 20% - 22% - Exercise Regularly
• 40% - 54% - Some Activity
• 24% - 40% - Sedentary
• 34% of pts are being counseled by physicians to begin or continue
exercise.
AHA Position Statement
Circulation 1991:86(1):340-44
Physical inactivity an as independent risk factor for the development of
CHD equal in status to the traditional risk factors of HTN,
DM, Dyslipidemia and smoking.
Exercise Type ?
• Most information is derived from aerobic exercise studies.
• Some evidence from occupational studies support that repeated busts of high energy output may offer protection against premature coronary mortality.
-Walking-Jogging-Cycling
High Intensity
AnaerobicCHO as Fuel
Low Intensity Aerobic
FFA as Fuel
Dynamic/Isotonic Exercise
Strength Training
Physiologic Adaptations to Exercise Training
• Chronic exercise of proper intensity, duration and frequency imposes a demand on the body.
• Consequently, the body makes appropriate and specific changes to accommodate the imposed demand.
Cardiovascular Adaptations with Aerobic Exercise
Decrease • Rest HR & BP
• Rest & Exercise RPP
• Exercise HR & BP (abs. WL)
• ESV
Increase
• LV Chamber
• EDV
• SV
• CO
• VO2 max
Cardiovascular Adaptations with Anaerobic Exercise
No Change
• Rest HR & BP
• Rest & Exercise RPP
• Exercise HR & BP (abs. WL)
• ESV
No Change
• LV Chamber ?
• EDV ?
• SV
• CO
• VO2 max
LVH with Aerobic and Anaerobic Exercise
AerobicVolume Load
Diastolic Stress
New Fibers in Series
Chamber size
Eccentric LVH
AnaerobicPressure Load
Systolic Stress
New fibers in parallel
Wall Thickness
Concentric LVH
CHD Death in Norwegian Men 40-59 years of Age (N=2,014)
0
2
4
6
1 2 3 4 Cross-countrySkiers
Lie et al. Eur Heart J ’85; 147-57
P<0.001
CH
D D
aeth
in 7
yr/
100
Fitness Quartiles
CVD Death in Men (N=10,224)
0
50
100
150
<7 7 8 9 10 11 12+
Blair et al. JAMA1989; 262:2395-2401
CV
D D
eath
/10,
000
per
son
-yea
rs
METs
A Prospective Study of Walking as Compared with Vigorous Exercise in
the Prevention of CHD in Women
Manson JE, et al., NEJM 1999;341:650-8
• N = 72,488 Female Nurses• Age : 40 to 65 yrs old in 1986• Free of CVD or Cancer• Follow-up: 8 yrs• Incidence of Coronary Events: 645
Fatal or Non-Fatal MI
Physical Activity & RR Adjusted for Confounding Factors (N=72,488)
1
0.880.81
0.74
0.66
0.4
0.8
1.2
1 2 3 4 5
Mason JE, et al. NEJM:’99;341:650-8
Physical Activity Quintiles
P<0.001
Relative Risk for Coronary Events and Walking Pace (n=72,488)
1
0.75
0.64
0.2
0.5
0.8
1.1
>30/mile 20-30/mile <20/mile
Mason JE, et al. NEJM:’99;341:650-8
Walking Pace (min/mile)
Relative Risk
Relative Risk for Coronary Events and Walking Time
1
0.78
0.88
0.7
0.65
0.5
0.7
0.9
1.1
<10 min 10 to 29 30 to 59 60 to 179 180 +
Mason JE, et al. NEJM:’99;341:650-8
Minutes Walking/Wk
RR
Relative Risk for Coronary Events and Walking Time in Women (n=72,488)
1
0.78
0.88
0.7
0.65
0.5
0.7
0.9
1.1
<10 min 10 to 29 30 to 59 60 to 179 180 +
Mason JE, et al. NEJM:’99;341:650-8
Minutes Walking/Wk
RR
F I N D I N G S• Brisk Walking for 100-200 min/week
at a Pace of <20 min/mile or <13 min/km. Reduces the Risk for Coronary Events in Women by 30 to 40 Percent.
• Similar Caloric Expenditure Yields Similar Reductions in Risk for Coronary Events.
Are Exercise Health BenefitsLong-Lasting?
The Harvard Alumni study (n=16,936) has shown that Ex-Varsity athletes retained lower risk for CHD only if they maintained a physically active
lifestyle throughout life.
Paffenberger et al., Am J Epidemiol 1978 108(3):161-175
Relative Risk of CHD & Aerobic Activity in Men (N=51,529)
1
0.87
0.79
0.58
0.5
0.7
0.9
1.1
None <30 min/Wk 30-60 min/wk >60 min/wk
Tanasescu M, et al. JAMA:’02;288:1994-2000
P<0.001
RR
Survival for Fit & Unfit Men (n=9,777)
0.6
0.7
0.8
0.9
1
0 4 8 12 16 18Follow-up Interval (yrs)
Unfit to Fit
Unfit to Unfit
Blair et al, JAMA 1995;273:1093-97
Survival Probability
44% Reduction in Risk
How Much Physical Activity?
How Much Exercise?• Not an easy Question
• Exercise Intensity, Duration and Frequency must be considered, as well as the interaction.
• Caloric expenditure is one approach.• Intensity still may play an independent
role.
Physical Activity and All –Cause and CVD Mortality in Women >65 yrs
1 1
0.73
0.65
0.77
0.7
0.620.6
0.68
0.58
0.4
0.7
1
<163 163-503 504-1045 1046-1906 >1907
Gregg EW, et al. JAMA’03;289:2379--86
Kcal/wk
Relative Risk
CVD
Weekly Energy Expanded and Relative Risk of CHD in Men (n=7,337)
1
0.80.84
0.5
0.7
0.9
<1000 1000-2499 2500+
Lee, I-Min et al. Circulation 2003;107:1110-16
Kcal/Week
Relative Risk
*
Age-adjusted First MI Rates by Physical Activity (n=16,963)
0
20
40
60
80
<500 500-999 1000-1999 2000-2999 3000-3999 4000+
Physical Activity ndex in Kcal/ Week
Total
Paffenbarger et al., Am J Epidem. 1978;108(3):161-75 MI/10,000 person-yrs
Non-Fatal
Fatal
Exercise Intensity and Relative Risk of CHD in Men (n=7,337)
10.98
0.75
0.6
0.9
<3 METs 3-6 METs >6 METs
Lee I-Min, et al. Circulation 2003;107:1110-16
Kcal/Week
Relative Risk
Exercise Intensity and Relative Risk of CHD in Men (n=7,337)
1
0.81
0.620.6
0.5
0.8
None Moderate Vigorous Very Vigorous
Lee I-Min, et al. Circulation 2003;107:1110-16Relative Risk
Relative Risk of All-Cause Death and Exercise Capacity
4.5
4.2
2.4
3
1.7
2.2
1.25
1.7
1 1
0
1
2
3
4
5
1 2 3 4 5
Quintiles of Exercise Capacity
<6 METS 6-7.9 METS 8-9.9 METS 10-12.9 METS >13 METS
RR of Death Myers J et al. NEJM 2002;346:793-801
Survival Curves for Normal and CVD Patients According to Exercise Capacity
Myers J et al. NEJM 2002;346:793-801
Conclusions
• Exercise Capacity is a more powerful predictor of mortality for CVD than other established risk factors.
• A linear reduction in mortality. For each 1 MET increase in exercise capacity, a 12%, decrease in mortality was observed.
Myers J et al. NEJM 2002;346:793-801
Exercise Capacity and Risk of Death in Women
21.6
10.5
1.5
2.5
3.5
<5 MET 5-8 MET >8 MET
Age-adjust
FRS-adjust
Hazard Ratio of Death
Gulati M, et al. Circulation 2003;108:1554-59
3.1
1.9
Exercise Capacity and Risk of Death in Women
Conclusions
• Exercise capacity is a strong and independent predictor of all-cause mortality in asymptomatic women, even after adjusting for traditional cardiac risk factors.
• For each 1 MET increase in exercise capacity, a 17%, decrease in mortality was observed.
Gulati M, et al. Circulation 2003;108:1554-59
Exercise Threshold for Health Benefits
METs < 4 – 5 7 10 ?
Threshold
• Intensity Fast walk Running
6 km/hr 10 km/hr• Kcal/wk 500 - 1000 3,000
• 120 min/wk 750 - 1050 1,500• 240 min/wk 1500-2100 3,000
Exercise in Patients with Risk factors and/or Chronic
Disease
Age-Adjusted CVD Death Rates &CHD Risk Factors (n=26,980)
46
22.513.2
2410 6.523
4.2 3.60
10
20
30
40
50
Low Moderate High
None
1
2
3
Blair, et al. JAMA 1996
Cardiorespiratory Fitness
Death Rate
51
27.512.6
46
22.513.224
10 6.523
4.2 3.60
20
40
60
Low Moderate High
None
1
2
3
Death Rate
12.6
51
27.5
46
Relative Risk of All-Cause Death and Exercise Capacity
1
1.3
1
1.3
1
1.35
1
1.6
1
1.5
0.5
1.5
2.5
HTN DM Smoke BMI>29 C>220 mg/dl
>8 Mets <5 Mets 5-8 Mets
RR of Death Myers J et al. 2002;346:793-801
CV Events and Physical Activity in Diabetic Women (n=5125)
1
0.93
0.82
0.54
0.3
0.7
1.1
<1 1-1.9 2-3.9 4-6.9
Hu F, et al. Ann Intern Med :’01;134;96-105Relative Risk
Hours/Wk
*
Body Weight/ Obesity
Relative Risk for Physical Activity & BMI, Adjusted For Risk Factors
1
0.79
0.88
0.71
0.82
0.65 0.65 0.64
0.69
0.54
0.4
0.6
0.8
1
1 2 3 4 5
Mason JE, et al. NEJM:’99;341:650-8
Physical Activity Quintiles
RR
>29
<29N=72,488
F I N D I N G S• Brisk Walking for 100-200 min/week
at a Pace of <20 min/mile or <13 min/km. Reduces the Risk for Coronary Events in Women by 30 to 40 Percent.
• Similar Caloric Expenditure Yields Similar Reductions in Risk for Coronary Events.
Relative Risk of All-Cause Death and Exercise Capacity
4.5
4.2
2.4
3
1.7
2.2
1.25
1.7
1 1
0
1
2
3
4
5
1 2 3 4 5Quintiles of Exercise Capacity
<6 METS 6-7.9 METS 8-9.9 METS 10-12.9 METS >13 METS
RR of Death Myers J et al. 2002;346:793-801
Normal CVD
Conclusions
• Exercise Capacity is a more powerful predictor of mortality for CVD than other established risk factors.
• A linear reduction in mortality. For each 1 MET increase in exercise capacity, a 12%, decrease in mortality was observed.
Myers J et al. 2002;346:793-801
S T R O K E
The NIH Consensus Development Panel on Physical Activity and CVD
JAMA ‘96;276:241-46
Data are inadequate to determine
whether stroke incidence is
affected by physical activity or
exercise training.
Physical Activity and Risk of Stroke in Women
Hu FB, et al , JAMA 2000;283:2961-67
• N=72,488 Female Nurses with no CVD or Cancer at Baseline
• Age: 40-65 years
• Follow-up: 8 years (560,087 person-years)
• 407 Strokes• 258 Ischemic• 67 Subarachnoid Hemorrhages• 42 Intracerebral & 40 of Unknown type
Multivariate Relative Risk of Total Strokes
1 0.98
0.820.74
0.66
0.5
0.7
0.9
1.1
1 2 3 4 5
MET Quintiles
Relative Risk
P=0.005
Multivariate RR for Ischemic Strokes
1
0.87 0.830.76
0.52
0.4
0.6
0.8
1
1 2 3 4 5
MET Quintiles
Relative Risk
P=0.003
Multivariate Relative Risk of Total Strokes by Walking Activity
1
0.76 0.780.7 0.66
0.4
0.6
0.8
1
0-0.5 0.6-2.0 2.1-3.8 3.9-10 10+
Relative Risk
P=0.01
METS
Multivariate Relative Risk of Ischemic Strokes by Walking Activity
1
0.77 0.750.69
0.6
0.4
0.6
0.8
1
0-0.5 0.6-2.0 2.1-3.8 3.9-10 10+
Relative Risk
METS
p=0.02
RR of Total Strokes by Walking Pace
1 1
0.66
0.81
0.36
0.49
0.2
0.4
0.6
0.8
1
<2mph 2-2.9 mph 3+ mph
Relative Risk
P<0.001
Age-Adjusted
Multivariate
Relative Risk of Hemorrhagic Strokes by Walking Pace
1 1
0.73
0.82
0.5
0.57
0.3
0.5
0.7
0.9
<2mph 2-2.9 mph 3+ mph
Relative Risk
P<0.02 Age-Adjusted
MultivariateP<0.06
Findings and Conclusions
Sedentary women who became active in middle to late adulthood had significantly lower risk for:
• Total Strokes : 27% - Age-adjusted 20% -
Multivariate • Ischemic Strokes: 38% - Age-adjusted
30% - Multivariate
Findings and Conclusions• Walking pace is strongly
associated with risk of stroke, Independent of the number of hours spent walking.
• Comparable magnitudes of risk reduction with equivalent energy expenditures from walking and vigorous activity.
Body Fat
HTN Dyslipidemia
DM Type II
Physical Activity
Endothelial Function
??
Cardiac Function
Hypertension
Kokkinos P., et al. Cardiology Clinics 2001;19(3):507-516
Average Reduction in BP: Active: 10.5/7.6 mm Hg Controls: 3.8/1.3 mm Hg
BP Changes with Exercise
-10
-8
-6
-4
-2
0
mm Hg
16 weeks 32 weeks
Kokkinos ,Pittaraset al. NEJM 1995;333:1462-7
SBP
DBPP<0.05
BP Changes with Exercise
-12
-10
-8
-6
-4
-2
0
mm Hg
SBP DBP
2 Wks
16 Wks16 Wks
2 Wks
Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients
1
1.3
2
0.2
0.7
1.2
1.7
2.2
>8 MET 5-8 MET <5 MET
RR of Death Myers J et al. 2002;346:793-801
LVMI at Baseline and 16 Weeks
163
143
125
140
155
170
Kokkinos, Pittaras et al. NEJM 1995;333:1462-7
*
* p<0.05
Baseline 16 weeks
Wall Thickness at Baseline and 16 wks
11
12
13
14
15
PW IVS
mm
Kokkinos, Pittaras et al. NEJM 1995;333:1462-7
*
*
* p<0.05
Left ventricular hypertrophy is a powerful and independent
predictor of cardiovascular events in patients with and
without obstructive coronary disease.
Ghali JK et al., 1992; Ann Intern Med 1992;117:831-36 Koren MJ et al., 1991; Ann Intern Med 1991;114:345-52 Casale PN, et al., Ann Intern Med 1986;105:173-78
LV Mass and Stroke
1 1
1.59
2.5
2.72 2.8
5.49
6.14
0
1
2
3
4
5
6
7
1 2 3 4
Odds Ratio
Quartiles of LV Mass
Unadjusted Adjusted
Rodriguez et al., JACC 2002;39(2):1482-8
LVH, Physical Activity and Risk of Stroke
1.59 1.781.42 1.64 1.79
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Total Men Women 40-60 yrs >60 yrs
Adjusted Odds Ratio Rodriguez et al., JACC 2002;39(2):1482-8
3.53
4.79
2.9
3.923.29
Active
LVH, Physical Activity & Risk of Stroke
1
0.4
3.48
0.66
0
1
2
3
4
No LVH LVH
Odds Ratio
SedentaryActiv
e
Rodriguez et al., JACC 2002;39(2):1482-8
SBP Following Aerobic Training
138131
198
171
219
187
219
199
120
140
160
180
200
220
Rest 6-Min 9-Min Peak
*
*
*
p<0.01
*
Kokkinos et al, AJC 1997
May mitigate the May mitigate the hemodynamic load hemodynamic load
during daily physical during daily physical activities.activities.
Attenuate the Attenuate the development and/or development and/or progression of LVH.progression of LVH.
Heart Failure
Skeletal Muscle
Atrophy Patient Adapts
Sedentary LifestyleDiminished
Aerobic Capacity
Muscular Changes
CardiorespiratoryChanges
Neurohormonal Changes
Kokkinos et al.. AHJ:140(1): 2000
All Cardiac Event Survival for HF Patients
0
0.2
0.4
0.6
0.8
1
0 200 400 600 800 1000 1200 1400 1600Time (Days)
Surv
ival
Trained
Untrained
Belardinelli et al, Circulation ‘ 99;99:1173-82
Hospitalization for Heart Failure
0.4
0.6
0.8
1
0 200 400 600 800 1000 1200 1400 1600Time (Days)
Surv
ival
pro
babi
lity
Belardinelli et al, Circulation ‘ 99;99:1173-82
Trained
Untrained
Cardiac Deaths for HF Patients
0.2
0.4
0.6
0.8
1
0 200 400 600 800 1000 1200 1400 1600Time (Days)
Surv
ival
Belardinelli et al, Circulation ‘ 99;99:1173-82
Trained
Untrained
Lipid & Lipoprotein Metabolism
Changes in Lipids & Lipoproteins with Exercise and Diet in Men
-30
-20
-10
0
10
20
Wood et al., NEJM 1991;325:461-6% Change
TG LDL-C
HDL-C
Control Diet Diet+Ex
Changes in Lipids & Lipoproteins with Exercise and Diet in Women
-20
-10
0
10
20
Wood et al., NEJM 1991;325:461-6% Change
TG
LDL-C HDL-C
Control Diet Diet+Ex
Is There A Dose-Response Relationship?
A dose-response relationship between HDL-C Levels and
weekly distance run or weekly caloric expenditure is supported
by most studies.
HDL-C and Km Run/Week:A dose-Response Relationship
47
49
51
53 53
56
460-3 4 to 10 11 to 16 17 to 22 23 to 32 33+
Kokkinos P., et al. Arch Intern Med ‘95;155:415-20mg/dL
Km/Week
*
*p<0.001N=2,906
Is There An Exercise Threshold?
The exercise-induced changes in lipid metabolism are likely the result of the interaction among exercise:
Intensity, Duration, Frequency and Length of Training.
It is also likely that an exercise threshold exists for each of these exercise components.
HDL-C and Weekly Distance
47
49
51
53 53
56
46
50
54
58
0-3 4 to 10 11 to 16 17-22 23-32 32+
Kokkinos P., et al. Arch Intern Med ‘95;155:415-20
Km/Week
mg/dL
N=2,906
p<0.001
*
*
Carbohydrate Metabolism
The Association between Cardiorespiratory Fitness and Impaired Fasting Glucose and
Type II DM
Wei M, et al., Ann Intern Med 1999;130:89-96
• N = 8,633 Non-Diabetic Men
• Age : 30 to 79 yrs old
• 7,511 Had Normal Fasting Blood Glucose
• Follow-up: 6 yrs
• 149 Developed DM and 593 Developed Impaired Fasting Glucose
Cardiorespiratory Fitness & Relative Risk for Type II Diabetes
3.7
1.7
1
0.5
1.5
2.5
3.5
Low Moderate High
Wei M, et al. Ann Intern Med:1999;130:89-96
Fitness Levels
Relative Risk
p<0.001
Cardiorespiratory Fitness & Relative Risk for Impaired Fasting Glucose
1.9
1.5
1
0.5
1
1.5
2
Low Moderate High
Wei M, et al. Ann Intern Med:’99;130:89-96
Fitness Levels
Relative Risk
p<0.001
Cardiorespiratory Fitness & RR for Impaired Fasting
Glucose & Type II Diabetes in Women (n=338)
4.85
2.7
1
0
1
2
3
4
5
Low Moderate High
Fitness Levels
Relative Risk
p<0.001
Cumulative Incidence of Diabetes
0
10
20
30
40
0.5 1 1.5 2 2.5 3 3.5 4
Follow-up Interval (yrs)
Placebo
Diabetes Prevention Program Research Group NEJM 346 (6) 393-403
Cumulative Incidence of DM (%)
Lifestyle
Metformin
Plasma Fasting Glucose
100
105
110
115
0 0.5 1 1.5 2 2.5 3 3.5 4
Follow-up Interval (yrs)
Placebo
Diabetes Prevention Program Research Group NEJM 346 (6) 393-403
Plasma Glucose (mg/dl
Lifestyle
Metformin
Glycosylated Hemoglobin
5.7
5.9
6.1
6.3
0 0.5 1 2 3 4
Follow-up Interval (yrs)
Placebo
Diabetes Prevention Program Research Group NEJM 346 (6) 393-403
Glycosylated Hemoglobin (%)
Lifestyle
Metformin
Conclusions• Lifestyle changes and treatment
with metformin both reduced the incidence of DM in persons at high risk.
• Lifestyle intervention was more effective than metformin.
• Number of pts need to be treated for 3 yrs to prevent 1 case of DM is 6.9
for the lifestyle intervention and 13.9 for metformin.
Plasma Glucose Levels Before & After Aerobic Training
100
120
140
160
180
200
0 30 60 90 120
Minutes After Glucose Ingestion
Plasma Glucose (mg/dl)Smutok et al. Metabolism ‘93
Post-Training
Pre-Training
*
*
Plasma Glucose Levels Before & After Strength Training
100
120
140
160
180
200
0 30 60 90 120
Minutes After Glucose Ingestion
Plasma Glucose (mg/dl) Smutok et al. Metabolism ‘93 ‘
Post-Training
Pre-Training*
*
*
Plasma Insulin Levels Before & After Aerobic Training
5
25
45
65
85
105
0 30 60 90 120
Minutes After Glucose Ingestion
Plasma Insulin (U/ml) Smutok et al. Metabolism ‘93
Post-Training
Pre-Training
*
*
Plasma Insulin Levels Before & After Strength Training
5
25
45
65
85
105
0 30 60 90 120
Minutes After Glucose Ingestion
Plasma Insulin (U/ml) Smutok et al. Metabolism ‘93
Post-Training
Pre-Training
* *
Body Weight/ Obesity
Relative Risk for Physical Activity & BMI, Adjusted For Risk Factors
1
0.79
0.88
0.71
0.82
0.65 0.65 0.640.69
0.54
0.4
0.6
0.8
1
1.2
1 2 3 4 5
Mason JE, et al. NEJM:’99;341:650-8
Physical Activity Quintiles
RR
>29
<29
N=72,488
Cardiorespiratory Fitness & CVD Mortality in Men (N=25,714)
1
3.1
1.5
4.5
1.6
5
0
1
2
3
4
5
BMI<25 BMI 25-29.9 BMI 30+
Wei M, et al.JAMA:’99;282(16);1547-53Relative Risk
(Normal)
(Over WT)
(Obese)
Fit
Unfit
CVD Mortality Predictors in Normal WT Men (BMI 18.5-24.9)
1.4
2.1 2.2
2.6
3.1
0
1
2
3
4
TC Smoke DM HTN Low Fit
Wei M, et al.JAMA:’99;282(16);1547-53Relative Risk
CVD Mortality Predictors in Overweight Men (BMI 25-29.9)
2.8
3.33.4
3.9
4.5
2
3
4
5
TC Smoke HTN DM Low Fit
Wei M, et al.JAMA:’99;282(16);1547-53
Relative Risk
CVD Mortality Predictors in Obese Men (BMI >30)
4.44.5
4.7
4.95
3.5
4.5
5.5
Smoke HTN TC DM Low Fit
Wei M, et al.JAMA:’99;282(16);1547-53Relative Risk
These findings suggest that it is as important for a clinician to
assess the fitness status of patients, (especially obese) as it is to assess blood glucose, TC,
HTN and smoking habits.
Exercise Recommendations
• Aerobic Activity 3-5 times/wk
• Brisk Walk to Slow Jog
• 60% to 80% of PMHR
• 100 to 200 minutes/week• 1200 to 2400 Kcal/Wk
LVMI at Baseline and 16 Weeks in Patients with LVH
163
143
130
150
170
Kokkinos, Pittaras et al. New Engl J Med 1995;333:1462-7
Baseline 16 weeks
*
* p<0.05
g/m2
Wall Thickness at Baseline and 16 wks
13.3
12.3
14.9
14
11
12
13
14
15
PW IVS
mm
Kokkinos, Pittaras et al. New Engl J Med 1995;333:1462-7
*
** p<0.05
How Much Physical Activity ?
• Do something
• Choose something you enjoy
Start Low & Progress Slowly
• Increase duration by 1-2 min/wk
• Be Consistent (2-5 times/week)
• Goal: 100-200 minutes/week
Exercise Training is Governed By Three Principles
• Specificity
• Overload
• Reversibility
The Specificity Principle
Biological Systems will Make
Specific Adaptations to
Accommodate an Imposed
Demand !
SPECIFICITY
Aerobic• Long Duration (>10
min)
• Low Intensity (<85% of PMHR)
• ATP via TCA Cycle
• FFA as Fuel
Anaerobic• Short Duration
(<5 min)
• High Intensity ( >90% of PMHR)
• ATP via Glycolysis
• CHO as Fuel
The Overload Principle
The performance of a Biological
System will Improve Only If the
Demand Imposed upon it is
Greater than the System is
Currently Accustomed.
Overload Principle
Frequency, Duration
and/or Intensity Must be Increased Periodically.
Reversibility Principle
Training adaptations diminish
if stimulation (training)
is discontinued for a length of
time (12 -90 days).
Exercise Components
• Frequency - Times/Wk
• Duration - Min/Session
• Intensity - How Hard
• Length - How many Wks
Frequency
• 2- 5 Times per Week
• Exercise Every Other Day
• Multiple Short Daily Sessions
(5-10 min) for Those with
Functional Capacity < 3 METS
Duration• 20-60 Minutes/Session of
Continuous Aerobic Activity
• Multiple Daily Sessions (~ 10
min) for Those with Functional
Capacity < 3 METs.
• Slow, Progressive Increase
Length of Training
Most Exercise Benefits Are Evident Within 12 Weeks of
Consistent Training.
ACSM Exercise Intensity Classifications
METS %PMHR
• Low <4 35-59
• Moderate 4-6 60-79
• High > 6 > 80
Exercise For Overweight & Obese Patients
Exercise Modality that does not Impose Excessive
Orthopedic Stress (walking, stationary bike,
aquatic exercises).
Exercise Intensity for Patients on Chronotropic Medications
Base Exercise intensity on
50% to 80% of Peak HR
achieved during ETT.
METs & Kcal for 30 Minutes of Select Physical Activities (80-kg person)
Activity METs Kcal• Fast Walk 5 200• Jog (12 min/mile) 8 320• Bike (Stationary) 7 280• Health Club 7 280• Dancing 5 200• Stair Climbing 5 200
Contraindications & Recommendations for Exercise
• Complete Physical
• Resting BP< 190/105 mm Hg
• Exercise BP <240/120 mm Hg• Exercise SBP drop >10 mm Hg (baseline)
• Unable to complete 5 METs (ETT) or climb
a flight of stairs without severe SOB or symptoms. Gill et al. JAMA 2000
Relative Risk of Onset of MI with Physical Activity
7
1.3
0
2
4
6
8
Relative R
isk
Inactive Active
Willich et al. NEJM '93
Relative Risk of Onset of MI with Physical Activity
107
20
82.4
0
30
60
90
Relative R
isk
0 1 to 2 3 to 4 5+
Mittleman et al. NEJM '93
The relative MI Risk for a 50-yr-old Non-smoking, Non-diabetic Man during a given hour is 1 in 1 million. If this man were sedentary and engaged in heavy physical exertion during that hour, his risk would increase 100 times or 1 in 10,000.
Framingham Heart Study